With COVID-19 spreading across the globe, healthcare providers on the front lines have to select the tools that will offer them and their patients the support they need. For clinicians that are considering using Vapotherm high velocity therapy on their patients, here is an overview of the full utility spectrum of this tool for a more informed decision-making process.
A Mask-Free, Comfortable Alternative to Non-invasive Positive Pressure Ventilation (NiPPV)
Vapotherm high velocity therapy is Mask-Free NIV® for spontaneously breathing patients and as such a viable alternative to NiPPV (e.g. BiPAP®). Unlike pressure-based respiratory support modalities, it achieves oxygenation and ventilatory support through a high velocity flush of the patient’s end-expiratory gas. This mechanism converts the nasal, oral, and pharyngeal spaces into a reservoir of optimally conditioned gas and significantly decreases work of breathing.[1,3,4] Additionally, because Vapotherm high velocity therapy is an open system and not pressure-based, it may decrease the risk of barotrauma events seen with NiPPV. This is a tool that supports the full range of respiratory distress seen in spontaneously breathing patients and is appropriate for any age patient population.[1,5,6,7]
Although Vapotherm high velocity therapy is a form of NIV, its open system and design lend it several patient-tolerance and comfort benefits traditionally associated with high flow devices. The interface is a soft, loosely-fitting cannula that ensures patients can eat, drink, take oral medication, and comfortably communicate with their caregiver. This well-tolerated interface requires minimal patient coaching and is an attractive alternative to mask-based interfaces, which require clinician time for fitting and adjusting. The conglomeration of these features may lead to high patient compliance with the therapy and potentially save clinician time managing non-compliant patients. Additionally, the lack of a tight seal on the interface reduces the risk of pressure injuries by comparison to NiPPV modalities.
Secretion Mobilization Through Optimal Humidification
Vapotherm high velocity therapy delivers optimally humidified medical grade vapor that may help mobilize secretions present in respiratory infections, such as pneumonia. The system uses a membrane filtration technology, as opposed to a water-pot humidifier. A warm-water jacketed delivery tube ensures that the gas temperature remains energetically stable all the way to the patient. This design not only minimizes the need for condensation management, but also delivers the humidified gas all the way to the patient where it can effectively humidify airway mucosa which is important to maintaining mucociliary health.
Fast Disinfection Process and Workflow Streamlining
Fast decontamination of equipment is always crucial in hospital settings but becomes even more relevant when clinicians are handling large volumes of patients. Vapotherm high velocity therapy uses a single-use, disposable patient circuit. Once a patient has been taken off the treatment, the circuit is disposed of and the device can be disinfected and ready for use in under five minutes. Additionally, the patient circuit has integrated aerosolized drug delivery capabilities, offering clinicians optionality in treatment and minimizing their contact with patient secretions.
This one tool offers a wide continuum of care. Vapotherm high velocity therapy allows clinicians to treat spontaneously breathing patients in acute respiratory distress which traditionally would have required NiPPV, whether these patients need support of oxygenation or ventilation. Having one, easy-to-tolerate tool available for this range of respiratory distress reduces the need to switch modalities with changes in patient condition.
What is the Risk of Nosocomial Transmission?
As with all viral infections, preventing transmission during treatment is an important consideration. The situation is developing rapidly and early guidance for nosocomial prevention is beginning to be issued by health organizations and institutions. Although some guidance suggests caution in the use of high flow devices and NIV in favor of intubation, other guidance urges clinicians to reconsider intubating patients given the high levels of monitoring and patient management required during mechanical ventilation.
Currently the risk of Vapotherm high velocity therapy transmitting the virus is unknown. One of the considerations for why it might not increase transmission is that the device operates at maximum flows of 40L/min. For comparison, a normal adult cough reaches 360-400 L/min flows. For more considerations on the topic, you can read this letter.
Visit our COVID-19 Resource Center for up-to-date answers to additional frequently asked questions.
 Doshi, Pratik et al. High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial. Annals of Emergency Medicine, 2018. https://www.ncbi.nlm.nih.gov/pubmed/29310868
 Dysart K, Miller T, Wolfson M, Shaffer T. Research in high flow therapy: Mechanisms of action. Respiratory Medicine. 2009; 103: 1400-05.
 Spivey S, Ashe T, Dennis R, Graham R, Melton B, Crot S, Ellis T, McCarl T, Miller J, Anderson S, Green T, Dunlap C, Kolnsberg M, Miller T. Assessment of high flow nasal cannula therapy use in the emergency department setting: observations of practice across four systems. Respiratory Therapy. 2015: 10(1); 30-4.
 Atwood C, Miller T, McMillan N, Hartwig K, Camhi S, Schweikert H. Effect of high flow highly humidified air via nasal cannula on respiratory effort in patients with advanced COPD. 2011 Oct; 10(4).
 Lavizarri A, Colnaghi M, Ciuffini F, Veneroni C, Musumeci S, Cortinovis I, Mosca F. “Heated, humidified high-flow nasal cannula vs nasal continuous positive airway pressure for respiratory distress syndrome of prematurity – a randomized clinical noninferiority trial.” JAMA Pediatr. 2016 Aug 8.
 Kugelman A, Riskin A, Said W, Shoris I, Mor F, Bader D. A randomized pilot study comparing heated humidified high-flow nasal cannulae with NIPPV for RDS. Pediatric Pulmonology, 2014 Mar 12; 50(6) 576-83.
 Collins C, Holberton J, Barfield C, Davis P. A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants. J Pediatrics. 2013 May; 162: 949-54.
 Black J, Kalowes P. Medical Device-Related Pressure Ulcers. Chronic Wound Care Management and Research Volume 3; 29 August 2016 Volume 2016:3 Pages 91—99.
 Williams R, Rankin N, Smith T, Galler D, Seakins P. “Relationship between the humidity and temperature of inspired gas and the function of the airway mucosa.” Critical Care Medicine. 1996 Nov;24(11):1920-9.
 Cheung JC-H, Ho LT, Cheng JV, Cham EYK, Lam KN. Staff safety during emergency airway management for COVID-19 in Hong Kong. The Lancet Respiratory Medicine. 2020.
 Farkas, Josh. “Covid-19.” The Internet Book of Critical Care. 2020, Mar 2. Last Accessed: March 5, 2020 https://emcrit.org/ibcc/COVID19/
 Mellies, Uwq and Christof Goebel. “Optimum Insufflation Capacity and Peak Cough Flow in Neuromuscular Disorders.” Annals of the American Thoracic Society. Volume 11, Issue 10. 2014. https://doi.org/10.1513/AnnalsATS.201406-264OC